Independent Rural Health Center/Freestanding Federally Qualified Health Center Cost Report and Supp. Regs in 42 CFR Sections 413.20 and 413.24 (CMS-222)

08-94 FORM CMS-222-92 2901

2900. GENERAL

These forms must be used by all independent rural health clinics (RHCs) and freestanding Federally qualified health centers (FQHCs). These forms are required for determining Medicare payment for RHC and FQHC services under 42 CFR 405, Subpart X.

An RHC/FQHC must complete all applicable items on the worksheets. For its initial reporting period, the facility completes these worksheets with estimates of costs and visits and other information required by the reports. The intermediary uses the estimates to determine an interim rate of payment for the facility. Following the end of the facility’s reporting period, the facility is required to submit its worksheets using data based on its actual experience for the reporting period. This information is used by the intermediary as the basis for determining the total Medicare payment due the RHC/FQHC for services furnished Medicare beneficiaries.

2 900.1 Rounding Standards for Fractional Computations.--Throughout the Medicare cost report, required computations result in the use of fractions. Use the following rounding standards for such computations:

1 . Round to 2 decimal places:

a . Rates

b . Cost per visit

c . Cost for pneumoccocal vaccine

2 . Round to 6 decimal places:

a . Ratios

b . Limit adjustments

2901. RECOMMENDED SEQUENCE FOR COMPLETING FORM HCFA-222-92

Part I - General Statistics and Expense Reclassification

and Adjustments

Step

No. Worksheet Page(s)

1 S, Part I 1 Read §§2903 and 2903.1. Complete Part I.

2 A 3 & 4 Read §2904. Complete columns 1 through 3, lines 1 through 62.

3 A-1 5 Read §2905. Complete entire worksheet if applicable.

4 A 3 & 4 Read §2904. Complete columns 4 and 5, lines 1 through 62.

5 Supp. A-2-1, 6 Read §2909. Complete entire Parts I-III worksheet as applicable.

6 A-2 7 Read §2906. Complete entire worksheet.

7 A 3 & 4 Read §2904. Complete columns 6 and 7, lines 1 through 62.

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2901 (Cont.) FORM HCFA-222-92 08-94

Part II - Computation of Medicare Cost

Step

No. Worksheet Page(s)

1 Supp. B-1 8 Read §2910. Complete if applicable.

2 B, Parts I-II 9 Read §§2907 through 2907.2. Complete entire worksheet.

Part III - Calculation of Reimbursement Settlement

Step

No. Worksheet Page(s)

1 C, Parts I-III 10 Read §§2908 through 2908.3. Complete entire worksheet.

2 S, Part II 2 Read §2903.2. Complete certification statement.

2902. SEQUENCE OF ASSEMBLY

The following list of assembly of worksheets is provided so all facilities are consistent in the order of submission of their annual cost report. All facilities using Form HCFA-222-92 are to adhere to this sequence. Where worksheets are not completed because they are not applicable, blank worksheets are not included in the assembly of the cost report.

2902.1 Sequence of Assembly - Worksheets.--

Worksheet Part(s)

S I & II

A N/A

A-1 N/A

A-2 N/A

Supp. A-2-1 I, II, & III

B I & II

B-1 N/A

C I, II, & III

2903. WORKSHEET S - INDEPENDENT RURAL HEALTH CLINIC/FEDERALLY QUALIFIED HEALTH CENTER STATISTICAL DATA AND CERTIFICATION STATEMENT

2903.1 Part I - Statistical Data.--At the top of the worksheet, indicate by checking the appropriate box whether the cost report being filed is a projected or an actual/final cost report.

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L ine 1.--Enter the full name of the RHC/FQHC. If the cost report is for multiple sites, see worksheet S, Part III.

L ine 1.01.--Enter the street address and P.O. Box (if applicable) of the RHC/FQHC.

L ine 1.02.--Enter the city, state and zip code of the RHC/FQHC.

L ine 1.03.--Enter the county of the FQHC..

L ine 2.--Enter the RHC/FQHC identification number that was provided by CMS.

L ine 3.--For FQHCs only, enter your appropriate designation (“U” for urban or “R” for rural). See §505.2 of the RHC/FQHC Manual for information regarding urban and rural designations. If you are uncertain of your designation, contact your intermediary. Do not complete this line for RHCs.

L ine 4.--Enter on the appropriate lines the inclusive dates covered by these worksheets. A reporting period is a period of 12 consecutive months for which a clinic must report its costs and utilization. The first and last reporting periods may be less than 12 months but not less than one month or greater than 13. A cost reporting period exceeding 13 months are subject to the provisions of CMS Pub. 15-2, section 102.1A.

L ine 5.--

C olumn1--Type of Control--Indicate the ownership or auspices of the RHC/FQHC by entering the number below that corresponds to the type of control of the RHC/FQHC.

V oluntary Non Profit Proprietary Government

1=Corporation 3=Individual 7=Federal

2=Other (specify) 4=Corporation 8=State

5=Partnership 9=County

6=Other ( specify) 10=City

11=Other(specify)

I f item 2,6, or 11 is selected, “Other (specify)” category, specify the type of provider in

column 2 of the worksheet.

C olumn 3.--Type of Provider--Enter the number which corresponds to the type of provider as defined in the conditions of participation. Enter 1 for a RHC and 2 for a FQHC.

C olumn 4.--Date Certified--Enter the date the RHC/FQHC was certified for participation in the Medicare program.

L ine 6.--

Column 1--Source of Federal Funds--Indicate the source of Federal Funds by entering the number below that corresponds to the applicable source.

1=Community Health Center (Section 330(d), Public Health Service Act)

2=Migrant Health Center (Section 329 (d), Public Health Service Act)

3=Health Services for the Homeless ( Section 340 (d), Public Health Service Act)

4 =Appalachian Regional Commission

5 =Look-Alikes

6 =Other (Specify)

I f item 6 is selected, “Other (Specify) category, specify the source in Column 2 of the worksheet.

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C olumn 3 --Enter the grant award number.

C olumn 4 --Enter the date the grant was awarded.

L ine 7.--In Column 1,list all physicians furnishing services at the RHC/FQHC and in Column 2 list the physician’s Medicare billing number. Also in Column 2, list any other Medicare Part B billing number used by the RHC/FQHC.

L ine 8.--In Column 1, enter the name of all supervisory physicians and in Column 2, enter the number of hours spent in supervision.

L ine 9.--Does the facility operate as other than a RHC or FQHC? Enter “Y” for yes or “N” for no.

L ine 10.--If the answer on line 9 is yes, enter the type of operation (i.e., laboratory or physicians services).

L ine 11.--Enter the hours of operation (from/to) based on a 24 hour clock next to the appropriate day that the facility is available to provide RHC/FQHC services. For example 8:00am is 0800 and 5:30pm is 1730.

L ine 12.--If the answer on line 9 is yes, enter the hours of operation (from/to) next to the appropriate day that the facility is available to provide other than RHC/FQHC services.

L ine 13.--Indicate whether this is a low or no Medicare utilization cost report, Enter an “L” for low Medicare utilization or “N” for no Medicare utilization. (See 42 CFR 413.24 (h)).

L ine 14.--Indicate whether this facility is filing a consolidated cost report under CMS Pub. 100-4, chapter 9, section 30.8. Enter “Y” for yes or “N” for no. If yes, complete a separate Worksheet S, Part III for each clinic filing on the consolidated cost report.

2903.2 Part II - Certification Statement.--The certification statement must be prepared and signed after the worksheets have been completed. The individual signing this statement must be an officer or other administrator.

2 903.3 Part III - Statistical Data for Clinics Filing Under Consolidated Cost Reporting.--This worksheet must be completed by each clinic filing under consolidated cost reporting. Indicate on each worksheet the corresponding clinic identification number under which the facility is certified to furnished Medicare services. Do not re-enter clinic information already entered on Worksheet S, Part I for the primary clinic.

L ine 1.--Enter the full name of the RHC/FQHC.

L ine 2.--Enter the street address and P.O. Box (if applicable) of the RHC/FQHC.

L ine 3.--Enter the city, state and zip code of the RHC/FQHC.

L ine 4.--Enter the county of the FQHC. RHCs are not required to provide this information.

L ine 5.--Enter the RHC/FQHC identification number that was provided by CMS.

L ine 6.--For FQHCs only, enter your appropriate designation (urban or rural). See §505.2 of the RHC/FQHC Manual for information regarding urban and rural designations. If you are uncertain of your designation, contact your intermediary. Do not complete this line for RHCs.

L ine 7.--On subscripts of line 7, in column 1, list all physicians furnishing services at the RHC/FQHC and in Column 2 list the physician’s Medicare billing number. Also in Column 2, list any other Medicare Part B billing number used by the RHC/FQHC.

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L ine 8.--On subscripts of line 8, in column 1, enter the name of all supervisory physicians and in Column 2, enter the number of hours spent in supervision.

L ine 9.--Does the facility operate as other than a RHC or FQHC? Enter “Y” for yes or “N” for no.

L ine 10.--If the answer on line 9 is yes, enter the type of operation (i.e., laboratory or physicians services).

L ine 11.--Enter the hours of operation (from/to) next to the appropriate day that the facility is available to provide RHC/FQHC services.

L ine 12.--If the answer on line 9 is yes, enter the hours of operation (from/to) next to the appropriate day that the facility is available to provide other than RHC/FQHC services.

2904. WORKSHEET A - RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES

Use Worksheet A to record the trial balance of expense accounts from your books and records. The worksheet also provides for the necessary reclassification and adjustments to certain accounts. All cost centers listed do not apply to all RHCs/FQHCs using this worksheet. For example, a facility might not employ laboratory technicians and does not, in that case, complete line 8. In addition to those lines listed, the worksheet also provides blank lines for other facility cost centers.

If the cost elements of a cost center are maintained separately on your books, a reconciliation of costs per the accounting books and records to those on this worksheet must be maintained by you and are subject to review by your intermediary.

U nder certain conditions, a provider may elect to use different cost centers for allocation purposes. These conditions are stated in CMS Pub. 15-I, §2313.

S tandard (i.e., preprinted) CMS line numbers and cost center descriptions cannot be changed. If a provider needs to use additional or different cost center descriptions, it may do so by adding additional lines to the cost report. Added cost centers must be appropriately coded. Identify the added line as a numeric subscript of the immediately preceding line. That is, if two lines are added between lines 5 and 6, identify them as lines 5.01 and 5.02. If additional lines are added for general services cost centers.

A lso, submit the working trial balance of the facility with the cost report. A working trial balance is a listing of the balances of the accounts in the general ledger to which adjustments are appended in supplementary columns and is used as a basic summary for financial statements.

C ost center coding is a methodology for standardizing the meaning of cost center labels as used by health care providers on the Medicare cost reports. The Form CMS 222-92 provides for 33 preprinted cost center descriptions that may apply to RHC/FQHC services on Worksheet A. In addition, a space is provided for a cost center code. The preprinted cost center labels are automatically coded by CMS approved cost reporting software. These 27 cost center descriptions are hereafter referred to as the standard cost centers. One additional cost center description with general meaning has been identified. This additional description will hereafter be referred to as a nonstandard label with an "Other..." designation to provide for situations where no match in meaning to the standard cost centers can be found. Refer to Worksheet A, line 9.

T he use of this coding methodology allows providers to continue to use labels for cost centers that have meaning within the individual institution. The four digit cost center codes that are associated with each provider label in their electronic file provide standardized meaning for data analysis. The preparer is required to compare any added or changed label to the descriptions offered on the standard or nonstandard cost center tables. A description of cost center coding and the table of cost center codes are in Table 5 of the electronic reporting specifications.

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Column Descriptions

Columns 1 through 3.--The expenses listed in these columns must be in accordance with your accounting books and records.

Enter on the appropriate lines in columns 1 through 3 the total expenses incurred during the reporting period. Detail the expenses as Compensation (column 1) and Other (column 2). The sum of columns 1 and 2 must equal column 3. Record any needed reclassification and adjustments in columns 4 and 6, as appropriate.

Column 4.--Enter any reclassification among cost center expenses which are needed to effect proper cost allocation.

Worksheet A-1 is provided to compute the reclassification affecting the expenses specified therein. This worksheet need not be completed by all facilities but must be completed only to the extent that the reclassification is needed and appropriate in the facility’s circumstances.

NOTE: The net total of the entries in column 4 must equal zero on line 62.

Column 5.--Adjust the amounts entered in column 3 by the amounts in column 4 (increase or decrease) and extend the net balances to column 5. The total of column 5, line 62, must equal the total of column 3, line 62.

Column 6.--Enter on the appropriate lines the amounts of any adjustments to expenses indicated on Worksheet A-2, column 2. The total on Worksheet A, column 6, line 62, must equal the amount on Worksheet A-2, column 2, line 12.

Column 7.--Adjust the amounts in column 5 by the amounts in column 6 (increases or decreases) and extend the net balances to column 7.

Transfer the amounts in column 7 to the appropriate lines on Worksheet B and Supplemental Worksheet B-1.

Line Descriptions

Lines 1 through 11.--Enter the costs of your health care staff on the appropriate line by type of staff.

Line 12.--Enter the sum of the amounts on lines 1 through 11.

Line 13.--Enter the cost of physician medical services furnished under agreement.

Line 14.--Enter the expenses of physician supervisory services furnished under agreement.

Line 16.--Enter the sum of the amounts on lines 13 through 15.

Lines 17 through 23.--Enter the expenses of other health care costs.

Line 24.--Enter the sum of the amounts on lines 17 through 23.

Line 25.--Enter the sum of the amounts on lines 12, 16, and 24. Transfer this amount to Worksheet B, Part II, line 10.

Lines 26 through 36.--Enter the overhead expenses related to the facility.

Line 37.--Enter the sum of the amounts on lines 26 through 36.

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L ines 38 through 48.--Enter the expenses related to the administration and management of the clinic.

L ine 49.--Enter the sum of the amount on lines 38 through 48.

L ine 50.--Enter the sum of lines 37 and 49. Transfer the total amount in column 7 to Worksheet B, Part II, line 14.

L ines 51 through 56.--Enter the cost centers applicable to services other than RHC/FQHC services (excluding overhead).

L ine 57.--Enter the sum of the amounts on lines 51 through 56.

L ines 58 through 60.--Enter the cost of services that are not reimbursable under Medicare.

L ine 61.--Enter the sum of the amounts on lines 58 through 60.

L ine 62.--This is the total cost of the facility. It is the sum of the amounts on lines 25, 50, 57, and 61.

2 905. WORKSHEET A-1 - RECLASSIFICATION

T his worksheet provides for the reclassification of certain amounts to effect the proper cost allocation. The cost centers affected must be specifically identifiable in your accounting records. Use reclassifications in instances in which the expenses applicable to more than one of the cost centers listed on Worksheet A are maintained in your accounting books and records in one cost center. For example, if a physician performs administrative duties, the appropriate portion of his/her compensation, payroll taxes and fringe benefits must be reclassified from "Facility Health Care Staff Cost" to "Facility Overhead", line 38 for the office salaries and line 45 for the benefits and taxes.

2 906. WORKSHEET A-2 - ADJUSTMENTS TO EXPENSES

T his worksheet provides for adjusting the expenses listed on Worksheet A, column 5. Make these adjustments, which are required under the Medicare principles of reimbursement, on the basis of cost, or amount received. Enter the total amount received (revenue) only if the cost (including the direct cost and all applicable overhead) cannot be determined. However, if total direct and indirect cost can be determined, enter the cost. Once an adjustment to an expense is made on the basis of cost, you may not, in future cost reporting periods determine the required adjustment to the expense on the basis of revenue. Enter the following symbols in column 1 to indicate the basis for adjustments: "A" for costs and "B" for amount received. Line descriptions indicate the more common activities which affect allowable costs or result in costs incurred for reasons other than patient care and, thus, require adjustments.

T ypes of items to be entered on this worksheet are (1) those needed to adjust expenses incurred, (2) those items which constitute recovery of expenses through sales, charges, fees, etc, and (3) those items needed to adjust expenses in accordance with the Medicare principles of reimbursement. (See HCFA Pub. 15-1, §2328.)

I f an adjustment to an expense affects more than one cost center, record the adjustment to each cost center on a separate line on this worksheet.

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L ine Descriptions

L ine 1.--Investment income on restricted and unrestricted funds which are commingled with other funds must be applied together against the total interest expense included in allowable costs. (See HCFA Pub. 15-1, §202.2.)

A pply the investment income on restricted and unrestricted funds which are commingled with other funds against the Administrative, Depreciation - Buildings and Fixtures, Depreciation - Equipment, and any other appropriate cost centers on the basis of the ratio that interest expense charged to each cost center bears to the total interest expense charges to all of your cost centers.

L ine 5.--Enter the allowable home office costs which have been allocated to the facility. Use additional lines to the extent that various facility cost centers are affected. (See HCFA Pub. 15-1, chapter 21.)

L ine 6.--Obtain the amount to be entered on this line from Supplemental Worksheet A-2-1, Part II, column 6, line 5. Note that Worksheet A-2-1, Part II, lines 1 through 4, represent the detail of the various cost centers to be adjusted on Worksheet A.

L ine 8.--Enter the amount which represents the allowable cost of the services furnished by National Health Service Corp (NHSC) personnel. Obtain this amount from your intermediary.

L ines 9 and 10.--If depreciation expense computed in accordance with Medicare principles of reimbursement differs from depreciation expenses per your books, enter the difference on lines 9 and/or 10.

2 907. WORKSHEET B - VISITS AND OVERHEAD COST FOR RHCs/FQHCs

W orksheet B is used by the RHC/FQHC to summarize (1) the visits furnished by your health care staff and by physicians under agreements with you, and (2) the overhead costs incurred by you which apply to RHC/FQHC services.

2 907.1 Part I - Visits and Productivity.--Use Part I to summarize the number of facility visits furnished by the health care staff and to calculate the number of visits to be used in the rate determination. Productivity standards established by HCFA are applied as a guideline that reflects the total combined services of the staff. Apply a level of 4200 visits for each physician and a level of 2100 visits for each nonphysician practitioner.

L ines 1 through 9 of Part I list the types of practitioners (positions) for whom facility visits must be counted and reported.

C olumn 1.--Record the number of all full time equivalent (FTE) personnel in each of the applicable staff positions in the facility practice (See HCFA Pub. 27, §503 for a definition of FTEs).

C olumn 2.--Record the total visits actually furnished to all patients by all personnel in each of the applicable staff positions in the reporting period. Count visits in accordance with instructions in 42 CFR 405.2401(b) defining a visit.

C olumn 3.--This is the number of visits required by productivity standards. No entry is required.

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Column 4.--This is the minimum number of facility visits the personnel in each staff position are expected to furnish. Enter the product of column 1 and column 3.

Column 5.--Enter the greater of the visits from column 2 or column 4. Intermediaries have the authority to waive the productivity guideline in cases where you have demonstrated reasonable justification for not meeting the standard. In such cases, the intermediary could set any number of visits as reasonable (not just your actual visits) if an exception is granted. For example, if the guideline number is 4200 visits and you have only furnished 1000 visits, the intermediary need not accept the 1000 visits but could permit 2500 visits to be used in the calculation.

Line 4.--Enter the total of lines 1 through 3.

Line 8.--Enter the total of lines 4 through 7.

Line 9.--Enter the number of visits furnished to facility patients by physicians under agreement with you. Physicians services under agreements with you are (1) all medical services performed at your site by a physician who is not the owner or an employee of the facility, and (2) medical services performed at a location other than your site by such a physician for which the physician is compensated by you. While all physician services at your site are included in RHC/FQHC services, physician services furnished in other locations by physicians who are not on your full time staff are paid to you only if your agreement with the physician provides for compensation for such services.

2907.2 Part II - Determination of Total Allowable Cost Applicable To RHC/FQHC Services.--Use Part II to determine the amount of overhead cost applicable to RHC/FQHC services.

Line 10.--Enter the cost of RHC/FQHC services (excluding overhead) from Worksheet A, column 7, line 25.

Line 11.--Enter the cost of services (other than RHC/FQHC services) excluding overhead from Worksheet A, column 7, sum of lines 57 and 61.

Line 12.--Enter the cost of all services (excluding overhead). It is the sum of lines 10 and 11.

Line 13.--Enter the percentage of RHC/FQHC services. This percentage is determined by dividing the amount on line 10 (the cost of RHC/FQHC services) by the amount on line 12 (the cost of all services, excluding overhead).

Line 14.--Enter the total overhead costs incurred from Worksheet A, column 7, line 50. It is the sum of facility costs and administrative overhead costs.

Line 15.--Enter the overhead amount applicable to RHC/FQHC services. It is determined by multiplying the amount on line 13 (the percentage of RHC/FQHC services) by the amount on line 14 (total overhead).

Line 16.--Enter the total allowable cost of RHC/FQHC services. It is the sum of line 10 (cost of RHC/FQHC services other than overhead services) and line 15 (overhead services applicable to RHC/FQHC services).

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2908. WORKSHEET C - DETERMINATION OF MEDICARE PAYMENT

Use this worksheet to determine the interim all inclusive rate of payment and the total Medicare payment due you for the reporting period.

2908.1 Part I - Determination of Rate For RHC/FQHC Services.--Use Part I to calculate the cost per visit for RHC/FQHC services and to apply the screening guideline established by CMS on your health care staff productivity.

Line 1.--Enter the total allowable cost from Worksheet B, Part II, line 16.

Line 2.--Enter the total cost of pneumococcal and influenza vaccine from Supplemental Worksheet B-1, line 15.

Line 3.--Subtract the amount on line 2 from the amount on line 1 and enter the result.

Line 4.--Enter the greater of the minimum or actual visits by the health care staff from Worksheet B, Part I, column 5, line 8.

Line 5.--Enter the visits made by physicians under agreement from Worksheet B, Part I, column 5, line 9.

Line 6.--Enter the total adjusted visits (sum of lines 4 and 5).

Line 7.--Enter the adjusted cost per visit. This is determined by dividing the amount on line 3 by the visits on line 6.

L ines 8 through 18.--Complete columns 1 and 2 of lines 8 through 18 to identify costs and visits affected by different payment limits during a cost reporting period. For lines 11 through 18, enter in column 3 the sum of columns 1 and 2 (and 2.01, if applicable). Enter the rates and the corresponding data chronologically in the appropriate column as they occur during the cost reporting period. For example, if only one payment limit is applicable during the cost reporting period complete column 1 only. Column 2 can be subscripted to accommodate the possibility of three per visit limits during a cost reporting period.

Line 8.--Enter the maximum rate per visit that can be received by you. Obtain this amount from PM A-03-21 or from your intermediary.

Line 9.--Enter the lesser of the amount on line 7 or line 8.

2908.2 Part II - Determination of Total Payment.--Use Part II to determine the total Medicare payment due you for covered RHC/FQHC services furnished to Medicare beneficiaries during the reporting period.

Line 10.--Enter the rate for Medicare covered visits from line 9.

Line 11.--Enter the number of Medicare covered visits excluding visits subject to the outpatient mental health services limitation from your intermediary records.

Line 12.--Enter the subtotal of Medicare cost. This cost is determined by multiplying the rate per visit on line 10 by the number of visits on line 11 (the total number of covered Medicare beneficiary visits for RHC/FQHC services during the reporting period).

Line 13.--Enter the number of Medicare covered visits subject to the outpatient mental health services limitation from your intermediary records.

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Line 14.--Enter the Medicare covered cost for outpatient mental health services by multiplying the rate per visit on line 10 by the number of visits on line 13.

Line 15.--Enter the limit adjustment. This is computed by multiplying the amount on line 14 by the outpatient mental health service limit of 62 1/2 percent. This limit applies only to therapeutic services not initial diagnostic services.

Line 16.--Enter the total Medicare cost. This is equal to the sum of the amounts on lines 12 and 15.

Line 17.--Enter the amount credited to the RHC’s Medicare patients to satisfy their deductible liabilities on the visits on lines 11 and 13 as recorded by the intermediary from clinic bills processed during the reporting period. RHCs determine this amount from the interim payment lists provided by the intermediaries. FQHCs enter zero on this line as deductibles do not apply.

Line 18.--Enter the net Medicare cost. This is equal to the result of subtracting the amount on line 17 from the amount on line 16. Enter in column 3 the sum of the amounts in columns 1 and 2.

Line 19.--Enter 80 percent of the amount on line 18, column 3.

Line 20.--Enter the Medicare cost of pneumococcal and influenza vaccines and their administration from Worksheet B-1, line 16.

Line 21.--Enter the total reimbursable Medicare cost. This is equal to the sum of the amounts on lines 19 and 20.

Line 22.--Enter the total payments made to you for covered services furnished to Medicare beneficiaries during the reporting period (from intermediary records).

Line 23.--This is equal to the result of subtracting the amount on line 21 from the amount on line 22.

Line 24.--Enter your total reimbursable bad debts, net of recoveries, from your records.

L ine 24.01.—Enter the gross reimbursable bad debts for dual eligible beneficiaries. This amount is reported for statistical purposes only. These amounts also are included on line 24.(4/1/2004b)

Line 25.--Enter the total amount due to/from the Medicare program (sum of lines 23 and 24). This is the amount of the payment reconciliation.

2909. SUPPLEMENTAL WORKSHEET A-2-1 - STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS

In accordance with 42 CFR 413.17, cost applicable to services, facilities, and supplies furnished to you by organizations related to you by common ownership or control are includable in your allowable cost at the cost to the related organization subject to the exceptions outlined in 42 CFR 413.17(d). This worksheet provides for the computation of any needed adjustments to costs applicable to services, facilities, and supplies furnished to you by organizations related to you. In addition, certain information concerning the related organizations with which you have transacted business is shown. (See CMS Pub. 15-1, chapter 10.)

2909.1 Part I - Introduction.--If there are any costs included in Worksheet A which resulted from transactions with related organizations as defined in CMS Pub. 15-I, chapter 10, check the "Yes" box and complete Parts II and III.

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If there are no costs included in Worksheet A which resulted from transactions with related organizations as defined in CMS Pub. 15-1, chapter 10, check the "No" box and do not complete the rest of the form.

2909.2 Part II - Costs Incurred and Adjustments Required.--Cost applicable to services, facilities, and supplies furnished to you by organizations related to you by common ownership or control are includable in your allowable cost at the cost to the related organizations. However, such cost must not exceed the amount a prudent and cost conscious buyer pays for comparable services, facilities, or supplies that are purchased elsewhere.

Complete each line as necessary and complete all columns for each of those lines.

Column 1.--Enter the line number from Worksheet A which corresponds to the cost center for which the adjustment is being made.

Column 2.--Enter the cost center from Worksheet A for which the adjustment is being made.

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Column 3.--Enter the item of service, facility, or supplies which you obtained from the related organization.

Column 4.--Enter the cost to your organization for the service, facility, or supplies which were obtained from the related organization.

Column 5.--Enter the allowable cost of the service, facility, or supplies which were obtained from the related organization. The allowable cost is the lesser of the cost of the service, facility, or supplies to the related organization or the amount a prudent and cost conscious buyer pays for a comparable service, facility or supply purchased elsewhere.

Column 6.--Enter the amount in column 4 minus the amount in column 5. Transfer the(se) amount(s) to the corresponding line of Worksheet A, column 6.

2909.3 Part III - Interrelationship of Facility to Related Organization(s).-Use this part to show your interrelationship to organizations furnishing services, facilities, or supplies to you. The requested data relative to all individuals, partnerships, corporations or other organizations having either a related interest to you, a common ownership with you, or control over you as defined in CMS Pub. 15-1, chapter 10, is shown in columns 1 through 6, as appropriate.

Complete only those columns which are pertinent to the type of relationship which exists.

Column 1.--Enter the appropriate symbol which describes your interrelationship to the related organization.

Column 2.--If the symbol A, D, E, F or G is entered in column 1, enter the name of the related individual in column 2.

Column 3.--If the individual indicated in column 2 or the organization indicated in column 4 has a financial interest in you, enter the percent of ownership.

Column 4.--Enter the name of the related organization, partnership or other organization.

Column 5.--If you or the individual indicated in column 2 has a financial interest in the related organization, enter the percent of ownership in such organization.

Column 6.--Enter the type of business in which the related organization engages (e.g., medical drugs and/or supplies, laundry and linen service.)

2910. SUPPLEMENTAL WORKSHEET B-1 - COMPUTATION OF PNEUMOCOCCAL AND INFLUENZA VACCINE COST

The cost and administration of pneumococcal and influenza vaccine to Medicare beneficiaries are 100 percent reimbursable by Medicare. This worksheet provides for the computation of the cost of the pneumococcal vaccine.

Line 1.--Enter the health care staff cost from Worksheet A, column 7, line 12.

Rev. 7 29-13

2910 (Cont.) FORM CMS-222-92 01-05

Line 2.--Enter the ratio of the estimated percentage of time involved in administering pneumococcal and influenza vaccine injections to the total health care staff time. Do not include physician service under agreement time in this calculation.

Line 3.--Multiply the amount on line 1 by the amount on line 2 and enter the result.

Line 4.--Enter the cost of pneumococcal and influenza vaccine medical supplies from your records.

Line 5.--Enter the sum of lines 3 and 4.

Line 6.--Enter the amount on Worksheet A, column 7, line 25. This is your total direct cost of the facility.

Line 7.--Enter the amount from Worksheet A, column 7, line 50.

Line 8.--Divide the amount on line 5 by the amount on line 6 and enter the result.

Line 9.--Multiply the amount on line 7 by the amount on line 8 and enter the result.

Line 10.--Enter the sum of the amounts on lines 5 and 9. Transfer this amount to Worksheet C, Part I, line 2.

Line 11.--Enter the total number of pneumococcal and influenza vaccine injections from your records.

Line 12.--Enter the cost per pneumococcal and influenza vaccine injection by dividing the amount on line 10 by the number on line 11 and entering the result.

Line 13.--Enter the number of pneumococcal and influenza vaccine injections from your records.

L ine 14--Enter the cost per pneumococcal vaccine injection by multiplying the amount on line 12 by the amount on line 13.

Line 15--Enter the total cost of pneumococcal and influenza vaccine and its (their) administration by entering the sum of the amount in column 1, line 10 and the amount in column 2, line 10. Transfer this amount to Worksheet C, Part I, line 2.

Line 16--Enter the Medicare cost of pneumococcal and influenza vaccine and its (their)administration. This is equal to the sum of the amount in column 1, line 14 and column 2, line 14. Transfer the result to Worksheet C, Part II, line 20.

29-14 Rev. 7